Policy-making for NCDs: riddled with conflicts and contestation

The rising burden of non-communicable diseases (NCDs) globally has turned the policy makers’ attention towards regulating some of the common ‘risk’ products including tobacco, alcohol and ultra-processed foods rich in sugar, salt and harmful fats. Consumption of these products can have negative health impacts on people. NCDs are a major killer in India accounting for 60% of total deaths – or over 9.8 million deaths in the year 2014. India has taken regulatory measures to warn people about the health impact (ultra-processed food, tobacco, alcohol) and curb promotion and/or consumption of some of these products (tobacco, alcohol) while also realizing the need for a multisectoral response for the prevention and control of NCDs. However, the public health interests pursued through these regulatory measures often go against the economic interests of industries dealing with these products, and often also against any vested interests of certain sections of governments (that see trade in these products as a source of revenue and foreign investment). In addition, some international development agencies that are influential in driving the policy agenda and dialogues get associated, often indirectly, with industries dealing in these ‘risk’ products.  So the policy-making in this area remains a highly contested and conflicted process. Still largely missing in these policy battles, are, however, political will and actions to manage these conflicting interests.

This is not a new phenomenon; it’s an age old battle. We still see politicians with overt industrial interests and industry leaders themselves being part of committees/bodies making public health policies related to tobacco control and food safety. For example, governments in India provide subsidies, invest money and to some extent own the tobacco industry. These are overt conflicts of interest and issues which have already been written about, and discussed in the public domain.

Manipulation by association

It is not difficult to notice the indirect and subtle associations between the tobacco and ultra-processed food industry with governments and international development agencies.

Such associations are often ways for industries to build a more positive image (and legitimacy) and access policy makers for influencing public policies. For instance, the tobacco industry is notorious for its ingenuity in sustaining relationships with governments, across the world. ITC, India’s largest cigarettes manufacturer, funded the 10^th Sustainability Summit organized recently in the national capital. It has been funding these summits for a long time. In fact, these summits are being organized by the CII-ITC Center of Excellence for Sustainable Development. The government ministries (Housing & Urban Poverty Alleviation; Environment, Forests & Climate Change) and several government agencies were partners for the 10^th summit, as was GIZ (German Society for International Cooperation, Ltd.). A UNDP (United Nations Development Programme) representative appeared in the speakers’ list. No wonder the bigwigs of tobacco industry featured in key positions in these summits, often alongside ministers and influential policy makers. The summit brought back memories of the World Business and Development Awards, an initiative supported by the UNDP to recognize private sector players working to achieve Millennium Development Goals. ITC, whose main profits come from the cigarette business, won an award in the 2012 edition of the Initiative. In another example from earlier this year, the International Tax and Investment Centre (ITIC), a known front group of the tobacco industry with some big tobacco people as board members and sponsors, organized the 2015 Asia Pacific Tax Forum in Delhi. The forum featured high-level government delegations from the region, including ministers and top officials from the government of India. Taxation is a proven effective instrument for tobacco control and this is not the first time that the ITIC has tried to negatively influence taxation policies. Also in 2012, a day before government delegations from across the world – party to the WHO-Framework Convention on Tobacco Control (WHO-FCTC) – were to meet and deliberate on economics and trade related issues in Moscow, the ITIC had organized a briefing on tobacco excise taxation inviting these government delegations. The WHO-FCTC secretariat had to issue a note verbale to the member countries alerting them about ITIC’s tobacco industry connections and suggesting them to avoid participating in an ITIC organized briefing. The 2015 Asia Pacific Tax Forum had listed the World Bank as funder and supporter on their website, which they later removed.

Such indirect engagements of tobacco industry are not uncommon, nor undocumented; I have written elsewhere on how Indian cigarette companies have been using so-called independent industry groups to influence tobacco control policies in India. Pranay Lal through an editorial in Tropical Medicine and International Health and a comment in the Lancet highlights how some international aid agencies and development partners have indeed assisted the tobacco industry and some continue to do so.

The food industry, particularly the sectors related to ultra-processed food and sugary-beverages also present a similar story. Arun Gupta and others, in their commentary in the Economic and Political Weekly, demonstrate how the food industry used ‘manipulation by association’ as a strategy to undermine nutrition policies – from food industry voices in the Lancet to funding of Indian universities by Nestle. Indeed, so-called corporate social responsibility (CSR) and sustainability have provided popular and often legitimate avenues for these industries to partner with governments/reputed organizations and fund (read influence) research/programs related to health and development. While the disclosure by Coca-Cola, spending (on its own) 118.6 million USD on scientific research and health and wellbeing partnerships, many of which were reputed health organizations, in the US in the last five years might surprise us for the sheer scale of it, it is not new for Indian companies producing tobacco and sugary drinks in India to partner with and fund reputed health and development organizations. For example, PepsiCo, one of India’s largest producers of sugary drinks and ready snacks, and ITC, one of the largest cigarette manufacturers, have associated themselves with reputed health and development organizations to support initiatives including lifestyle and nutrition programs for children. In fact, nearly all the big tobacco and food/beverage companies in India produce ‘sustainability’ reports, often lengthier than their annual reports, highlighting their CSR contributions towards health, development and sustainability in general.

Corrective actions: too little, too late?

Article 5.3 of the WHO-FCTC, signed and fully ratified by India, requires member countries to adopt policies, which prevent conflicts of interest between governments and the tobacco industry’s interference in public policies with regard to tobacco control.  In a public interest litigation (Institute of Public Health Vs Union of India and others), the health ministry on behalf of the government of India had promised the Karnataka High Court to bring in a code of conduct for public officials with regard to their dealings with tobacco industry.  After over four years of the court intervention, the government is yet to adopt a code or a policy along these lines. There are some positive examples too: in 2013, the Karnataka government issued a letter to all the elected leaders and bureaucrats advising them not to participate and associate with tobacco-industry funded events. More recently, the Punjab government formulated a committee to focus on implementing the WHO-FCTC article 5.3. However, effective implementation remains a challenge as the incidence  of government and political representatives associations with the tobacco industry are not uncommon.

A member of parliamentarians from Tamil Nadu introduced the Prevention and Management of Conflicts of Interest bill in 2011, which lapsed and was subsequently reintroduced in 2015. The bill is still pending. Meanwhile, earlier this year, amendments were proposed to the existing national tobacco control legislation adding that the government of India should ‘protect the development and implementation of public health policies with respect to tobacco control from the commercial and other vested interest of the tobacco industry’. These amendments are still in a proposal form. While the WHO clearly denounces CSR activities of tobacco industry, the Companies Act (2013) by the Ministry of Corporate Affairs mandates CSR by big Indian companies, in turn legitimizing CSR by big tobacco and food companies in India.

Some development agencies have adopted policies of not supporting tobacco industry operations. The World Bank already did so in 1991. But the process is far from straightforward. By way of example: after we, at the Institute of Public Health (Bangalore), wrote to the Bank on the problematic nature of their association with the 2015 Asia Pacific Tax Forum, the Bank’s India office sent us a written response indicating that they had indeed received requests from the ITIC for financial and technical support, which, after careful consideration, the Bank had declined. Subsequently, the forum website removed the Bank’s mention as a supporter of the forum. However, soon after, the Bank was in the news for the wrong reasons (again) – its pension fund was invested in tobacco, coal and mining companies, especially mentioning the name of the tobacco giant, Philip Morris International, among others.

A letter to the UNDP by an Indian activist, Bobby Ramakant, pointed out problems with the UNDP giving the World Business and Development Award to the ITC. This yielded a response from the UNDP administrator, Helen Clark, regretting the oversight. Subsequently, while responding to a comment on UNDP’s associations with the tobacco industry, Helen Clark indicated that the UNDP is working out a policy in this regard. Inspired by UNDP’s proposal, we tagged UNDP on twitter questioning their participation in the tobacco industry funded Sustainability Summit. We received a response; they adopted a policy of not engaging with tobacco manufacturers in 2013 and deeply regretted the oversight. What is worrying is that many development partners do not have a policy in this regard and that those who do have such a policy in place are not fully compliant all the time. Our challenges to government agencies also led a few government agencies to regret their participation in the summit.

Need to denormalize ‘problematic partnerships’

There is a need to devise a comprehensive policy framework preventing conflicts of interest within governments/development agencies and prohibiting the CSR activities by industries producing products known to be harmful to health. We need to actively keep in check and denormalize such partnerships through timely actions. It is in this context that the civil society actions are important including initiatives such as the IndiaTobaccoWatch or the Alliance Against Conflicts of Interest. I sincerely hope that the government led by Mr. Narendra Modi with its stated ambition of ‘Minimum Government and Maximum Governance’ recognizes this problem as one of inadequate governance where economic interests are not managed in the broader ambition of human wellbeing. We do need both – effective governance and government interventions – especially when public health is at stake.

(Radhika Arora and Kristof Decoster provided some editorial support for this blog post)

Commitment to the poor and disadvantaged by the government comes at an opportune time. In spite of apparently progressive pro-poor schemes of the previous Congress-led government targeting rural employment guarantee and a more communitised health system (see Rajani Ved’s blog on India’s ASHA programme and Arima Mishra’s blog on the mission mode for India’s programmes), corruption and mal-administration plague India’s public services, as noted by R S Rajan. Modi ran on an election platform that showcased how his governance would be exactly NOT like the previous regime. In health, the Modi election manifesto promised “health assurance to all Indians and to reduce the out-of-pocket spending on health care”.

However, in a federal state, which is still battling with worse-off governance at state levels than the relatively better-off systems at the centre, this national health assurance is slowly proving to be a difficult promise to deliver. As Neethi Rao reflects in her blog on federalism, Indian states often with their own local state-level politics are not always in line with such national commitments, more so on health services organisation and delivery which is on the so-called state list. A much more systematic support at state and district levels is possibly needed before such national commitments may be fulfilled. While this complex socio-political negotiation between a PM at the centre, who portrays clear convictions on how to chart India’s development story, and a general poverty of governance and vision at the state level (with respect to health and development) continues, there are not yet clear positive trends for India’s health on the horizon.

If financing of healthcare is any indicator of government’s commitments to health of its people, the signals are not (yet) so positive. The precious little coming to the healthcare sector has to be partitioned between pet national institutes of excellence, even as a hugely under-funded and under-performing primary and secondary care system watches, as Shreelata Rao Seshadri notes in her blog. In spite of being a prominent supplier of inexpensive medicines to several countries in the global South, access to medicines in India’s own primary health centres is not yet optimal (see Maya Annie Elias’s blog on this topic). Early pronouncements of health insurance for all later morphed into health assurance for all with no clarity on how such assurance or insurance would supplement or rather undermine India’s large public sector. Budget cuts in the social sector programmes and schemes of the central government followed; again cutting of central government spending in the social sector was accompanied by higher revenue share to states, arguably favour of co-operative federalism. However, there are doubts that such trade-offs will work, at least they may not work in all states. Many of the worse-off states where targeted central assistance was in fact unconditionally focusing on the social sector, the shift of greater revenue to states might in fact be weaned away from supporting long-term social sector spending and may succumb to low politics at the state and be used for short-term vote-gain programmes.

While the debate on whether India ought to go for a privately provided market-based insurance route for UHC or veer towards publicly provided (or purchased) care is a debate that has strident advocates on either side, Modi government’s slogan of “minimum government, maximum governance” fails India on two counts. There is the actual need of quite some “government”, at least with respect to sectors like health, education and environment, where we know from several global experiences that reducing government’s stake to mere stewards while handing over organisation, management and delivery of these systems to non-governmental entities is a dangerous trend. The need for building a strong partnership with states and investing in multi-level governance system and effective regulation of private sector in health, especially the provision of healthcare by private entities is a crucial need for Indian public health.

In fact, if the current weakening of environmental norms in favour of quick-wins is any indication of times to come, then India’s short-term gains in infrastructure, investment and global image may come at a long-term health and environmental cost. As Shankar Raman reminds us, environmental effects on health are not marginal concerns any more. In its eagerness to make sure we all feel the development, the Modi government may be over-enthusiastically cosying up to big business. India’s environment ministry has been delivering clearances for clearing forest land for industry faster than ever before, and the rural development ministry has been steering land acquisition for industry directly, while the health ministry, after bold declarations against big tobacco delivered in much fanfare by Modi government’s own previous health minister, backtracked on implementing large-size health warnings on tobacco products. Corporate and industry interests are high priority and not without reason, but their influence on health, development and environmental policy is indeed worrisome. More so, when India’s biggest business interest groups that are involved in public policymaking bodies and several Indian parliamentarians in important committees related to health and development have very close ties to big tobacco. Indeed India’s finance minister, a close aide of Modi minces no words when he characterises his government as being “pro-poor and pro-industry“. How this marriage between unusual partners – pro-poor and pro-industry- works, time only will tell, as Ramaswami Balasubramaniam notes in his 1^st year report card for the Modi government.

Commitment to co-operative federalism and decentralisation may be a mantra on one hand, but the government’s attitude towards publicly expressed dissent has not always been well received. Many NGOs are on the Modi government’s radar, including environment campaigner Greenpeace, which has faced the ire of the government. Several NGOs being cracked down upon were dubious and were deservedly at the wrong end of the stick, but slowly and steadily an atmosphere intolerant of criticism and dissent seems to be cropping up; not a healthy trend warns Adithya Pradyumna in the blog ‘health of NGOs in India’.

Image consciousness is of course not always a bad thing. Modi’s leadership is clearly visible in his administration embracing social media and being accessible on the several government-run online platforms that are mushrooming. Many leading government officials are today on social media and sharing decisions and developments in their offices. Online platforms such as mygov widens reach of the somewhat common (wo)man (access to the Internet and more so, being vocal on that platform is still not so commonplace here). The trend of ministers making frequent public statements and not hesitating for open media debates is also healthy. However, it is still unclear as to how such social media and online platform engagement by citizens is used or feeds the policy process.

Amidst public debate on apparently farmer-unfriendly policies, the government faces stiff pressure to show a more human face to the large farmer base in the country. As Shridhar Kadam notes in his blog, India’s villages are unsure whether to enjoy the fruits of globalisation or miss the comfort of their erstwhile sustainable living. This is of course not only an Indian story but a global one, playing out differently in many of the emerging economies.

Clearly, the first year of Modi government has been different from the previous regime on most counts albeit the difference does not (yet) augur too well for health and environment. In any case, assessing a nation’s health based on one year of a new PM is a flawed enterprise. Nonetheless, broad public policy trends in favour of public health are not (yet) evident. If at all, close association with big business could indeed mean higher private sector role in healthcare delivery. What form this will take, how much of collaboration and how much of regulation is still to be seen (see for instance Vijayashree Yellappa’s reflection on this). Whether invited or not to the healthcare party, the private sector is here to stay. If indeed public health has to prevail, an effective regulatory system that reins in India’s unbridled private sector is a very large unfinished agenda in India. And irrespective of how private, or how public India’s healthcare future is, the Modi government needs to put more government (not less as they are hoping) in healthcare regulation (see Sunil Nandraj’s post on reining in India’s private sector). One only hopes that the crushing of bureaucratic barriers for big business will not be the downfall of public health and public institutions in India. Time only will tell. But, on one thing there is no doubt; health, education and environment in India require quite some government (not less) and certainly better regulation. In this respect the proposal in the draft national health policy 2015 to make access to healthcare a constitutional right in India is a bold and a very welcome move, only if Modi’s government in the remaining four years of its term make it into reality.

The draft National Health Policy 2015 makes for an interesting read. There is a distinct difference in the tone and semantics of the 2015 draft NHP as compared to the existing version of the policy. Its primary objective as stated by the draft document, “is to inform, clarify, strengthen and prioritize the role of the government in shaping health systems in all its dimensions – investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and legislation for health.” A long sentence, reflecting and articulating, perhaps for the first time in a policy document, the role of the government in the funding and the provision of health services. This is reflected in the acknowledgement that despite a robust private health sector, health outcomes and financial protection for the population are linked to public health expenditure. It’s also expressed in the intention to strengthen the provision of comprehensive care at the primary care level.

The NHP goes beyond presenting a generic statement of the challenges facing health and healthcare in India. Its text reflects research done over the past decade and also ongoing debates and controversies on health care; not missing the opportunity to leverage the incident of the deaths at a sterilization camp in November 2014, to critique the concept of camps as a legacy of past regimes. The draft NHP covers a range of topics from health financing, human resources in health and health research to the challenges presented by the demographic and epidemiological shifts.

To address the changing needs of the population, the draft NHP 2015 outlines seven key policy shifts which include expanding the focus on primary care to one that assures comprehensive care and effective referrals; strategic purchasing in secondary and tertiary care mainly from government providers; assured free drugs, diagnostics and emergency services in all public facilities; focus on infrastructure and human resource development – towards a more equitable distribution of health resources; integrating national health programmes with the broad health systems. In addition, the draft NHP proposes to address urban health issues – including, but not restricted to the social determinants of health. While the Swachh Bharat Abhiyan (or ‘clean India campaign’), did convince some wealthy citizens to pick up the broom and clean their already immaculate neighbourhoods, its broader campaign and awareness created a stir and discussion on the need for the physical cleanliness. It’s a start – but more needs to be done in terms of integrating it with the broader issues of sanitation, access to clean water and issues of planning and developing living and working spaces. One gets to see an explicit need for a social movement for health expressed in the draft. Lastly, the draft NHP 2015 focuses on mainstreaming Ayurveda, yoga, Unani, siddha and homeopathy (AYUSH). With the 21^st of June as being declared to be the International Day of Yoga and the formation of the new Ministry of Yoga, this last AYUSH initiative seems well on the road to implementation.

The threat of the spread of Ebola and India’s shaky capacity to be able to tackle an epidemic, if it should so occur hasn’t been lost on the NHP. The need to strengthen health systems and the role of government towards developing the capacity to prevent and address communicable diseases has been reiterated. The document also acknowledges the need to address chronic non-communicable diseases (and brings in the issues of integration, human resources as well as Indian systems of medicine here), as well as the preventable aspects of road safety and occupational hazards. The use of information communication and technology to supplement resources and improve outreach are also included.

There is much in this draft National Health Policy that researchers, activists and those working in the area of public health have been working on over the last few decades. Some of it new, some not. The issue of increasing public financing of health care, for example, has been highlighted by several governments. The draft NHP 2015 too acknowledges the need to increase public financing in health for it to meet the goals outlined, though it remains to be seen if this will actually happen.  This policy document positions health care and health services within social determinants. Equity and quality of care in access to health services underlie almost all recommendations. Perhaps the most significant debate to emerge from the draft policy is that on the right to healthcare and whether a bill should be passed to make access to healthcare a justiciable right, much like moves in education, food and employment by earlier governments in India.

Unlike the general neglect of the private sector in government’s discourse of health in India, the draft policy acknowledges its tremendous growth in India. Acknowledging its contribution to the Indian economy, the draft policy articulates why this sector cannot be counted on to provide what is not favoured by the market: preventive care in general and equitable care to a large majority of Indians who can ill afford it in private sector. While the proposed policy provides a clear rationale for and explicit intention  to  regulate, or rather actively  ‘influence’ the private sector to align its goals with public policy goals, the draft fails to provide even broad directions as to how this might be achieved.

The semantics of the 2015 draft NHP vary from past NHPs. Presented to the public just days after the media reported cuts in the health budget, the draft NHP 2015 throws up some pleasant surprises in terms of its objectives. For the moment, we need to wait and see how much of the content of the draft policy will distil into the final version, and how its objectives will be met. The proposal with rights-based language and centrality of state (government) intervention in health sector does not fit readily into what the new government seems to be up to, with the recent cuts in health budgets and appointment of Aravind Panagariya and Bibek Debroy (possibly the best advocates for market-based approaches to development) to NITI Ayog – a smaller and probably to be the most influential think-tank that replaced the Planning Commission of India a few days ago. As the common man awaits for ‘Acche Din’ or good times, the promise that galvanized the last election and brought the Modi government to power, it is yet to be seen whether the health sector will get enough attention and of what kind.